Limited femoral navigation versus conventional intramedullary femoral jig based instrumentation for achieving optimal restoration of mechanical axis post total knee arthroplasty: a prospective comparative study of 200 knees

Clinical outcomes associated with robotic and computer-navigated total knee arthroplasty: a machine learning-augmented systematic review

BACKGROUND

Robotic (RTKA) and computer-navigated total knee arthroplasty (CNTKA) are increasingly replacing manual techniques in orthopaedic surgery. This systematic review compared clinical outcomes associated with RTKA and CNTKA and investigated the utility of natural language processing (NLP) for the literature synthesis.

METHODS

A comprehensive search strategy was implemented. Results of included studies were combined and analysed. A transfer learning approach was applied to train deep NLP classifiers (BERT, RoBERTa and XLNet), with cross-validation, to partially automate the systematic review process.

RESULTS

52 studies were included, comprising 5,067 RTKA and 2,108 CNTKA. Complication rates were 0-22% and 0-16% and surgical time was 70-116 and 77-102 min for RTKA and CNTKA, respectively. Technical failures were more commonly associated with RTKA (8%) than CNTKA (2-4%). Patient satisfaction was equivalent (94%). RTKA was associated with a higher likelihood of achieving target alignment, less femoral notching, shorter operative time and shorter length of stay. NLP models demonstrated moderate performance (AUC = 0.65-0.68).

CONCLUSIONS

RTKA and CNTKA appear to be associated with similarly positive clinical outcomes. Further work is required to determine whether the two techniques differ significantly with regard to specific outcome measures. NLP shows promise for facilitating the systematic review process.

New technology-based assistive techniques in total knee arthroplasty: A Bayesian network meta-analysis and systematic review

BACKGROUND

The radiological and clinical efficiency among robot-assisted surgery (RAS), computer-assisted navigation system (CAS) and conventional (CON) total knee arthroplasty (TKA) remains controversial.

METHODS

Bayesian network meta-analysis (NMA) and systematic review were performed to investigate radiological and clinical efficiency respectively. The certainty of the evidence was evaluated using GRADE and CERQual tool.

RESULTS

Thirty-four RCTs (7289 patients and 7424 knees) were included. The NMA showed that RAS-TKA had the highest probability for mechanical axis restoration (odds ratio for RAS vs. CAS 3.79, CrI 1.14 to 20.54, very low certainty), followed by CAS-TKA (odds ratio for CAS vs. CON 2.55, CrI 1.67 to 4.01, very low certainty) and then CON-TKA, without significant differences in other radiological parameters. No differences were found in clinical outcomes after qualitative systematic review (overall low certainty).

CONCLUSIONS

Technology-based assistive techniques (CAS and RAS) may surpass the CON-TKA, when considering higher radiological accuracy and comparable clinical outcomes. This article is protected by copyright. All rights reserved.

Does the sequential addition of accelerometer-based navigation and sensor-guided ligament balancing improve outcomes in TKA?

AIMS

A significant percentage of patients remain dissatisfied after total knee arthroplasty (TKA). The aim of this study was to determine whether the sequential addition of accelerometer-based navigation for femoral component preparation and sensor-guided ligament balancing improved complication rates, radiological alignment, or patient-reported outcomes (PROMs) compared with a historical control group using conventional instrumentation.

METHODS

This retrospective cohort study included 371 TKAs performed by a single surgeon sequentially. A historical control group, with the use of intramedullary guides for distal femoral resection and surgeon-guided ligament balancing, was compared with a group using accelerometer-based navigation for distal femoral resection and surgeon-guided balancing (group 1), and one using navigated femoral resection and sensor-guided balancing (group 2). Primary outcome measures were Patient-Reported Outcomes Measurement Information System (PROMIS) and Knee injury and Osteoarthritis Outcome (KOOS) scores measured preoperatively and at six weeks and 12 months postoperatively. The position of the components and the mechanical axis of the limb were measured postoperatively. The postoperative range of motion (ROM), haematocrit change, and complications were also recorded.

RESULTS

There were 194 patients in the control group, 103 in group 1, and 74 in group 2. There were no significant differences in baseline demographics between the groups. Patients in group 2 had significantly higher baseline mental health subscores than control and group 1 patients (53.2 vs 50.2 vs 50.2, p = 0.041). There were no significant differences in any PROMs at six weeks or 12 months postoperatively (p > 0.05). There was no difference in the rate of manipulation under anaesthesia (MUA), complication rates, postoperative ROM, or blood loss. There were fewer mechanical axis outliers in groups 1 and 2 (25.2%, 14.9% respectively) versus control (28.4%), but this was not statistically significant (p = 0.10).

CONCLUSION

The sequential addition of navigation of the distal femoral cut and sensor-guided ligament balancing did not improve short-term PROMs, radiological outcomes, or complication rates compared with conventional techniques. The costs of these added technologies may not be justified. Cite this article: Bone Joint J 2020;102-B(6 Supple A):24-30.

Computer-Assisted Technologies in Arthroplasty: Navigating Your Way Today

Computer-assisted technologies that are used in arthroplasty include navigation, image-derived instrumentation (IDI), and robotics. Computer-assisted navigation improves accuracy and allows for real-time assessment of component positioning and soft-tissue tension. It is not clear whether the implementation of these technologies improves the clinical outcome of surgery. High cost and time demands have prevented the global implementation of computer-assisted technologies.

Comparison of a novel handheld accelerometer-based navigation system and conventional instrument for performing distal femoral resection in total knee arthroplasty: a randomized controlled trial

Background

This prospective study aimed to compare the efficacy of a novel, hand-held, accelerometer-based navigation system (i-JOIN knee navigation system) for distal femoral resection in total knee arthroplasty (TKA) with conventional instrument.

Methods

A multi-center, double-blinded, randomized controlled trial (RCT) was conducted. A total of 79 consecutive patients scheduled for primary TKA were enrolled and divided into navigation group (39 patients) and conventional group (40 patients). Post-operative mechanical and component position were evaluated through full-leg weight bearing X-ray. Pre-operatively and 1 week post-operatively, adverse events were recorded. Intraoperative surgical time and blood loss were also recorded.

Results

The mean outlier of 180° neutral mechanical axis was 1.60° (SD 1.11°) in navigation group and 2.30° (SD 2.06°) in conventional group (P=0.0917). Thirty-eight patients (97.4%) in navigation group and 35 patients (87.5%) in conventional group had an alignment which was ≤3°away from the neutral mechanical axis (P=0.2007). α angle between the navigation group and conventional group was not statistically different (89.81° vs. 89.76°, P>0.05), as well as adverse events rate post-operatively. The operative time of navigation group was significantly longer than that of control group (114.54±35.34 vs. 100.33±28.38 min, P=0.0493), whereas the intraoperative blood loss was not significantly different.

Conclusions

i-JOIN knee navigation system had equivalent results for distal femoral resection in TKA compared with the conventional technique.

Articular surface mounted navigated total knee arthroplasty improves the reliability of component alignment

PURPOSE

The primary aim was to compare the early knee-specific functional outcome after articular surface mounted (ASM) navigation with non-navigated TKA. The secondary aims were to compare general physical and mental health improvement, patient satisfaction, and reliability of component alignment in the sagittal and coronal planes between ASM navigated TKA with that of non-navigated TKA.

METHODS

Prospective functional outcome and radiographic data were collect for 123 patients undergoing ASM navigation and 172 patients undergoing non-navigated TKA by a high volume single surgeon. Pre-operative and one-year Oxford knee score (OKS) and short form (SF-) 12 scores were collected. Patient satisfaction was also assessed at one year. Implant position was assessed on post-operative radiographs (alpha, beta, gamma, and sigma angles) by a blinded observer.

RESULTS

There was no significant difference for improvement in OKS, SF-12 physical or mental components, or satisfaction between the groups one year following surgery. The non-navigation group was significantly more likely to have outliers (greater than 3 degrees) in femoral varus/valgus coronal alignment [odds ratio (OR) 4.5, 95% confidence interval (CI) 1.0-20.7, p = 0.049] and for posterior tibial slope (OR 8.3, 95% CI 1.1-65.0, p = 0.03).

CONCLUSIONS

ASM navigation significantly reduces the number of outliers for the femoral and tibial components when compared to conventional non-navigation alignment. However, the short-term functional outcome is not influenced by the surgical technique used. If the surgeon wants to reduce their number of outliers, then ASM navigation should be considered but the overall functional outcome in the short term is not influenced.

LEVEL OF EVIDENCE

III Therapeutic investigation, retrospective cohort study.